Family Solutions for Kids (FSK) Referral Form Date of Application County St. Louis Jefferson Child’s InformationChild’s NameDate of Birth Current Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent/Caregiver(s)Parent/Caregiver #1Parent/Caregiver Email #1 Parent/Caregiver Phone #1Parent/Caregiver #2Parent/Caregiver Email #2 Parent/Caregiver Phone #2Legal Guardian(s)If different than aboveLegal Guardian #1Legal Guardian Email #1 Legal Guardian Phone #1Legal Guardian #2Legal Guardian Email #2 Legal Guardian Phone #2Referred ByReferral NameReferral Email Referral PhoneRelationship to ClientFSK is voluntary. Does the family know they are being referred? Yes No Does the family prefer in-home, in-office or virtual services? In-home In-office Virtual Is the family willing to work with a Masters-level practicum student? Yes No FSK is intensive. Is the family available for 3-4 hours per week? Yes No Availability Morning Afternoon Evening (Mark all that apply)Is the family utilizing other services?(If so, please list)Names and ages of other children in the homeBriefly describe presenting concernsConsent(Required) Family Solutions for Kids is a program cooperatively operated by Every Child’s Hope (ECH) and Presbyterian Children’s Homes and Services (PCHAS). The program provides time-limited in-home and community-based therapy and case management services to children and families residing in St. Louis County. I understand supervisors of Every Child's Hope (ECH) and Presbyterian Children’s Homes and Services (PCHAS) will have access to confidential information I provide for the purpose of assigning the best Therapist to work with my family.
